Acute Viral Illnesses and Ischemic Stroke: Pathophysiological Considerations in the Era of the COVID-19 Pandemic

Abstract

The severe acute respiratory syndrome coronavirus 2 or coronavirus disease 2019 (COVID-19) pandemic has raised concerns about the correlation with this viral illness and increased risk of stroke. Although it is too early in the pandemic to know the strength of the association between COVID-19 and stroke, it is an opportune time to review the relationship between acute viral illnesses and stroke. Here, we summarize pathophysiological principles and available literature to guide understanding of how viruses may contribute to ischemic stroke. After a review of inflammatory mechanisms, we summarize relevant pathophysiological principles of vasculopathy, hypercoagulability, and hemodynamic instability. We will end by discussing mechanisms by which several well-known viruses may cause stroke in an effort to inform our understanding of the relationship between COVID-19 and stroke.

Keywords: coronavirus; ischemic stroke; pandemic; syndrome; viruses.

Figure 1.

Schematic of potential mechanisms by which viral infections can cause ischemic stroke.

Figure 2.

Select patterns of vasculopathy and ischemic stroke in varicella-zoster virus (VZV) infection. A, Magnetic resonance angiogram demonstrating vasculopathy involving the right middle cerebral artery territory in the setting of acute VZV infection. B, Diffusion-weighted imaging (DWI) sequence demonstrates deep region of restricted diffusion in acute VZV infection. C, Scattered areas of restricted diffusion on DWI imaging in the setting of subacute VZV infection.